1. ‘Enhancing musculoskeletal research in primary care: engaging a community musculoskeletal physiotherapy service in research studies’ Presented by : Carol Doyle On behalf of Allied Health Services Primary Care Therapies Team East Cheshire NHS Trust Let’s Talk Research – 24 th & 25 th September 2014

2. Who are we? Adult Musculoskeletal Physiotherapy Service Part of Primary Care Therapies Team Within East Cheshire NHS Trust Based in Primary Care settings Patients referred by GPs (mainly)

3. What do we do? Assessment, treatment and management of musculoskeletal conditions 25% of GP Consultations are musculoskeletal conditions Physiotherapy as part of their management Estimated 53 out of 1000 patients referred for musculoskeletal physiotherapy* *Holdsworth et al (2006): Are patients who refer themselves to physiotherapy different from those referred by GPs?

4. Are you getting the ‘best’ treatment for your back pain?

5. What do we know? Back pain is a common problem 8 out of 10 people will suffer an episode Majority of people nothing serious Patients suffer recurring episodes Many go on to develop long term disability / work problems Huge costs to NHS and society – £10688 million!* *Maniadakis et al (2000): The economic burden of back pain in the UK.

6. Why are we here? To share our ‘journey’ in developing a culture of evidence based practice To identify the ‘key’ elements To show the ‘results’ of our approach To look at the ‘impact’ to our service ‘Showcase our service’

7. How did it begin? The Drivers - 2000 onwards Organisational change –Restructuring Community Service in Primary Care –Beginning commissioning era Physiotherapy undergraduate education Early implementer of Knowledge Skill Framework (KSF)

8. What were the key elements? Management culture shift –‘Open door’ approach Creating a culture of Evidence Based Practice –Clinically and cost effective patient care –‘Futureproof’ service Involvement with research –‘Bridging the gap’ between academic and clinical communities

9. Who did we involve? Engagement at all levels of organisation Visionary Managers Committed Leaders Created links with Arthritis Research UK Primary Care Centre, Keele University New Physiotherapy Research Facilitator post Clinician involvement in high quality research studies

10. Which studies? Name of studyType of studyPatients Recruited (2599) Physios involved (138) Stratified Care for Low Back Pain (IMPaCT Back) 2007 – 2010* Implementation92226 Telephone assessment (PhysioDirect) Multicentre RCT527 (2249)8 Exercises for OA knee (BEEP)Multicentre RCT141 (526)10 Patient reported outcome measure (PROMS) Feasibility58 (428)7 Patient self-referral (STEMS)Pilot Cluster RCT 95117 Hip OA survey (ABC Hip)National Physio survey N/A70 posted

11. IMPaCT Back (2007-2010) Implementing a stratified care approach for low back pain in primary care Subgroup (STarT Back tool) and targeted treatments according to risk of poor outcome Before and after design Conducted in South Cheshire (5 GP practices) 922 patients recruited 64 GPs and 16 Physiotherapists involved

12. IMPaCT Back Results ‘Stratified care for low back pain improves clinical outcomes and is cost-effective’* Reduced sickness certification –15% before versus 9% after Significant improvements in disability (RMDQ) at 6mths – 0.71 (95%CI 0·06, 1.36), p<0.03 Significantly less time off work at 6mths – 50% reduction! *Foster et al (2014): Effect of Stratified Care for Low Back Pain in Family Practice (IMPaCT Back): A Prospective Population-Based Sequential Comparison “Stratified care for low back pain improves clinical outcomes and is cost effective “*

13. What has been the impact? Staff –Empowerment, evidence based training, career opportunities, retention Patients –Satisfaction, improved pathways, information, outcomes Service –Quality indicators (CQUIN), commissioning, innovation

14. ‘ Supports active engagement of staff in research in clinical setting, which raises standards of service delivery and effectiveness. Also supports wide range of staff training and development opportunities to support ongoing CPD’ Physiotherapy Manager

15. ‘Raises the service profile and provides a unique selling point for service promotion in business cases and tenders……..Supports the development of quality indicators that drive service improvement’ Physiotherapy Manager

16. ‘ It has enabled us to change our practice for the better e.g. IMPaCT Back and STEMS, and the training that Keele provided and are still providing to our service is invaluable’ Physiotherapist

17. ‘The interaction with Keele and the research facilitators has enabled me to enhance my skills and knowledge in research, the research facilitators have been key in making trials work seamlessly in clinical practice’ Physiotherapist

18. Acknowledgements

19. Thank you for listening! Contact: c.doyle@keele.ac.uk